Medicare beneficiaries have been among the hardest-hit populations by the pandemic for the last 13 months — about eight in 10 COVID-19 deaths were among people 65 and older. But the pandemic is not the first or only crisis our nation’s older adults have faced over the last several years. Seniors who depend on the Medicare Part D drug benefit are also the most likely to need life-saving prescriptions that they can’t afford.
It has been 15 years since the Part D prescription drug benefit was created, and although the program is popular, it has not kept pace with the needs of patients with life-threatening, chronic and rare diseases. The Medicare Part D benefit requires thoughtful updates to ensure the more than 46 million people who rely on the program can afford their prescribed medications.
Older adults can face substantial out-of-pocket health care costs in the form of insurance premiums, deductibles and coinsurance — including for physician visits, hospital stays and medical devices. They also pay out-of-pocket for non-covered but essential services such as vision, dental and hearing-related care. Piling on, out-of-pocket prescription medication spending can contribute significantly to seniors’ total health care expenses. According to a study by the Kaiser Family Foundation, the average annual out-of-pocket cost in 2019 for patients requiring a specialty medication was more than $8,000.
The sum of these health care costs can be insurmountable for those who have complex or chronic diseases — and especially for the one in two Medicare beneficiaries living on an annual income of less than $26,200.
We regularly hear heartbreaking stories from people who decided to forgo treatment for a serious illness because they could not afford to pay and did not want to be a financial burden to their family. Research backs this up: Even a monthly co-pay of $40 for a medication can cause many patients — especially those with lower or fixed incomes — to abandon their prescriptions. When a patient cannot stay on their medication because of the cost, it can lead to hospitalization, loss of independence and even death.
With pandemic relief bills behind them, Congress has the opportunity to take action to lower out-of-pocket costs for prescription drugs to ensure seniors no longer face impossible decisions between their health and paying for basic living expenses. Any future drug pricing legislation must include the following Medicare reforms to increase patient access to treatment:
An annual cap on patient medication costs: Medicare beneficiaries are the only insured group in the U.S. without a limit, or cap, on what they owe out-of-pocket for their medications. This burden must be addressed. There is bipartisan support for capping what Medicare beneficiaries spend out-of-pocket for their prescription medications. Previous legislation included different annual caps — $2,000 and $3,100. Both would be a welcome reform to the Medicare Part D program, but to truly help beneficiaries, this cap should be as low as possible.
Smoothing patient medication costs throughout the benefit year: Medicare Part D prescription drug plans concentrate out-of-pocket medication costs at the beginning of the year when deductibles and benefits reset. This cycle can have a devastating impact on patients who face high cost-sharing associated with medications for diseases such as Parkinson’s, cancer, diabetes and Alzheimer’s disease. Instead, Part D plans should be required to offer their enrollees the option of paying out-of-pocket costs in installments throughout the remaining months of a plan year. Beneficiaries who can pay in smaller increments will stand a better chance of adhering to treatment and reducing downstream health care costs — including costly hospitalizations — due to non-adherence.
Moving forward, patients must be at the center of any drug pricing legislation. We must ensure lower medication costs for beneficiaries while not unintentionally harming access to care or research into future cures.
This past year has been unlike any other for our nation’s seniors. They deserve a swift and collaborative legislative effort by policymakers that will help them afford treatments to protect, enhance and extend the quality of their lives.
Amy Niles is the executive vice president at the Patient Access Network Foundation. She previously served as chair, Medical Relations and Advocacy for the Together Rx Access program, and the president and CEO of the National Women’s Health Resource Center, now known as Healthy Women.
Michael Ward is the vice president of Public Policy at the Alliance for Aging Research. He oversees the Alliance’s public policy and advocacy efforts and has over a decade of experience advancing health care innovation through policy research, federal advocacy and partnership development.